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Expert Critique
FROM THE ASCO Reading Room
The idea behind behavioral therapies stems from the theory that gastrointestinal disorders are inherently linked to the brain-gut axis. In other words, treating the mind can have powerful benefits on bowel symptoms. In fact, results to date appear similar to those of the low-FODMAP diet which has gained traction as an effective diet for patients who suffer from IBS.
As described, a recent randomized controlled trial, the IMAGINE trial, found that 12 weeks of hypnotherapy resulted in marked symptom improvement in IBS patients, with results persisting up to 9 months. Lastly, the article points out that gastroenterologists have been slow to adopt hypnotherapy into their recommendations for IBS. While there may be some stigma associated with hypnotherapy, given the positive data with few associated side effects, I expect psychotherapy for IBS to gain a significant amount of traction over the next few years.
Back in 1984, Peter Whorwell, MD, PhD, at the University of Manchester, and colleagues conducted a groundbreaking randomized placebo-controlled of gut-directed hypnosis versus psychotherapy and placebo in 30 patients with irritable bowel syndrome (IBS).
While the psychotherapy group showed a small but significant improvement in abdominal pain, abdominal distension, and general well-being but not in bowel habits, hypnotherapy patients showed a dramatic and highly significant improvement in all features. No relapses were recorded in the hypnosis arm of the study during 3-month follow-up, and no substitution symptoms were observed.
Since then, results from approximately 30 additional clinical trials have been published on hypnosis treatment, almost all of them showing substantial therapeutic effects on bowel symptoms. Standardized programs such as the 12-session Manchester protocol and the seven-session North Carolina protocols have taken their place beside cognitive therapy as one of two psychological mainstays in IBS management.
Bidirectional Brain-Gut Axis
Since hypnosis capitalizes on the bidirectional brain-gut axis at work in IBS, hypnosis helps patients deal with persistent severe symptoms after medical management has failed. "Hypnosis is a really excellent option for treating functional GI disorders," Sarah K. Ballou, PhD, of Beth Israel Deaconess Hospital in Boston, told the Reading Room. "Incorporating psychological therapy that addresses the brain-gut interaction is so important since medicine does not always meet patients' needs."
In terms of symptom management, hypnosis has proven comparable to the low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. For example, a 2015 systematic by Simone Peters, PhD, and colleagues reported that six of seven randomized IBS studies of hypnotherapy had a significant reduction (all P <0.05) in overall gastrointestinal symptoms compared with use of supportive therapy only. Response rates among those who received gut-directed hypnotherapy ranged from 24% to 73%, with efficacy maintained long-term in four of five studies. (A therapeutic benefit was also observed in the maintenance of clinical remission in patients with ulcerative colitis.)
While one-on-one in-person therapy with a qualified therapist has accumulated the most data, mounting evidence suggests that hypnotherapy need not be given in this resource-intensive form – or reserved for refractory patients referred to specialty programs at tertiary-care centers. Like cognitive education, hypnotherapy can be successfully given in primary care, in groups, and as self-administered video-supported sessions at home, Peters and co-authors said.
More recently, the multicenter randomized controlled IMAGINE trial of 354 patients found that 12 weeks of therapist-delivered hypnotherapy significantly relieved complaints about IBS symptoms compared with educational supportive therapy at the primary and secondary care levels – with benefit persisting for 9 months.
Patients in both individual and group hypnotherapy had better rates of adequate response on a symptom-relief questionnaire compared with controls receiving standard educational support: 40.8%, 33.2%, and 16.6%, respectively. At 12 months, adequate relief was reported by 40.8% of patients in individual hypnotherapy, 49.5% of those in group hypnotherapy, and 22.6% (11.5-39.5) of controls.
And the finding that group hypnotherapy was non-inferior to individual hypnotherapy has implications for increasing timely accessibility and reducing healthcare costs. Currently, access to individual sessions is often restricted by long waiting lists for licensed therapists.
Similar results emerged from a randomized controlled Swedish trial of 108 refractory IBS patients, which was reported at the 2017 United European Gastroenterology Week. After 12 weeks of gut-directed hypnotherapy sessions, response rates in the individual sessions were not significantly different from those in the group sessions (69% vs 57%, P=0.018), the researchers reported.
Pain intensity, pain frequency, bloating severity, bowel habit dissatisfaction, and daily life interference associated with IBS all significantly improved after treatment.
And in 2015, Jenny Lovdahl, RN, and colleagues that 12 weeks of nurse-administered hypnosis produced favorable responses in a group of 85 IBS patients. "Hypnotherapy is being very successfully delivered by nurses to IBS patients in our community," Ballou said.
A 2017 randomized of 250 children by Juliette Rutten, MD, PhD, and colleagues reported that home-based hypnotherapy using CD instruction compared favorably with individual, therapist-delivered hypnosis in children with IBS. One year after treatment, 62.1% of children in the home CD group and 71.0% in the individual group were successfully treated.
"The noninferiority of home-based treatment with a hypnosis CD provides a rationale for implementation of this easy-to-use treatment in daily practice," the authors wrote in JAMA Pediatrics, cautioning that an application for a smartphone or tablet would better suit today's children than a CD.
Getting Past the 'Aura of Mystery'
Olafur S. Palsson PsyD, of the University of North Carolina, Chapel Hill, who pioneered the North Carolina protocol, noted that while gastroenterologists have embraced hypnotherapy, there is still an aura of mystery about it, especially among primary care physicians, who seem less aware of its potential benefits.
One of the big open questions is which patients are likely to respond to a course of hypnotherapy. "We don't yet know what those characteristics are," Palsson told the Reading Room. "People who have a lot of psychological distress, anxiety, or depression are probably not suitable candidates."
There is a common misconception, he added, that you have to be highly hypnotizable to respond, but people with a moderate degree of susceptibility are capable of response. "Basically it's suitable for anyone who has an open mind and is willing to work at it," Palsson said. "But it's not a passive therapy. If patients don't engage, they don't respond."
Ballou said that while once patients may have been leery of hypnosis, they are now increasingly open to the option, and she said she offers hypnotherapy to a growing number of patients. "There has been a lot of media coverage about it in the past couple of years, and many patients now ask me specifically for hypnosis before I even bring it up," she said.
And she said that although she herself practices one-on-one in-person hypnotherapy, many patients choose other options, such as online video programs. For example, "the online IBS program offers hypnotherapy in different modalities and has had very promising results," she said.
While new options allow for faster and earlier access to hypnotherapy, one of its pluses is longevity: "Patients enjoy the benefits of a single course for multiple years," Palsson said. "In four out of five cases the effects last half a decade."
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